Surgical Procedures: Surgery and Staging for Rectal Cancer

Author: OncoLink Team
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Cancerous (malignant) cells in the rectum are called rectal cancer. The rectum and anal canal are about 6-8 inches long. They make up the end of the large intestine, fully ending at the anus where stool exits the body.

Most commonly, rectal cancers start in adenomatous polyps of the rectum. Adenomatous polyps are a precancerous condition that can turn into cancer and may invade the rectal wall. Other less common types of rectal cancers are:

  • Carcinoid tumors.
  • Gastrointestinal stromal tumors (GISTs).
  • Lymphomas.
  • Sarcomas.

What is staging and how is it performed?

Staging is a way to find out if and where the cancer has spread in your body. Your provider will have you get a few tests to figure out the stage of your cancer. For rectal cancer, these tests may be:

Physical Exam: This is a general exam to look at your body and to talk about past health issues. 

Imaging: Radiology tests can look inside your body at the cancer and see if it has spread. These tests can include: 

Laboratory Testing: Blood tests such as blood chemistry, a complete blood count, CEA (carcinoembryonic antigen) assay and testing for blood in the stool may be recommended.

Procedures: Each case of rectal cancer is different. Talk with your care team about which procedures may be part of your treatment plan. These options may include:

  • Fecal Occult Blood Testing: Also known as guaiac-based fecal occult blood test (gFOBT) and fecal immunochemical test (FIT), these tests will test for blood in the stool.
  • Stool DNA testing: This test looks for abnormal DNA found within the stool.
  • Blood testing: Your healthcare team may want to test your levels of carcinoembryonic antigen (CEA) in your blood, which may be tested and tracked over time.
  • Colonoscopy: A colonoscope (lighted, flexible tube) is inserted into the rectum, reaching the whole colon to check for any abnormalities. A biopsy may be done during this test.
  • Sigmoidoscopy: A sigmoidoscope (lighted, flexible tube) is inserted into the rectum and the lower portion of the colon called the sigmoid colon to evaluate for any abnormalities. A biopsy may be done during this test.
  • Double-contrast barium enema (Lower GI series): This test uses the liquid enema contrast barium which is put into your rectum. It helps to show any abnormalities on X-rays taken of the lower gastrointestinal tract which includes the colon and the rectum.
  • Biopsy: Biopsies may be obtained to send to the lab to check for cancer and possibly a genetic mutation called hereditary nonpolyposis colorectal cancer.

Rectal cancer spreads to other parts of the body through the tissue, lymph and blood systems. Cancer stage determines how extensive the cancer, how far it has spread and what treatment course will be recommended. Rectal cancer is described as stages 0 through stage IV disease.

Often times, it may be recommended that those with rectal cancer undergo surgery.

Surgical Procedures for Rectal Cancer

There are several surgical procedures used to treat rectal cancer, depending on your particular stage and situation, including:

  • Polypectomy/Local excision:  A colonoscope (as in the colonoscopy) is used to remove a polyp or abnormal area of cancer. During a polypectomy, only the polyp is removed, whereas during a local excision (also known as an endoscopic mucosal resection), some of the tissue on the rectal wall is also removed.
  • Local transanal resection (Full thickness resection): This is removal of the cancer within the rectum, as well as surrounding healthy tissue through the anus. Some lymph nodes and the tissue lying between the rectum and abdominal wall may be removed. In some cases, the surgeon may use a magnifying scope to perform a transanal endoscopic microsurgery (TEM).
  • Low anterior resection (LAR):  Removes the affected tissue in the upper portion of the rectum. Some healthy tissue and lymph nodes are also removed for testing and the colon and rectum are surgically re-connected. Sometimes a temporary ileostomy will be done to allow for adequate healing.
  • Abdominoperineal resection (APR): The anus, anal sphincter and surrounding tissue are removed, requiring a permanent colostomy.
  • Proctectomy with colo-anal anastomosis: The entire rectum is removed, connecting the colon directly to the anus. At times, surgeons will create a pseudo rectum using a part of the colon which will then store fecal matter for elimination. In some cases, there is a need for a temporary ileostomy.
  • Radiofrequency ablation: Electrodes kill cancer through a probe inserted through the skin or an abdominal incision.
  • Cryosurgery: Abnormal cells are frozen and killed.
  • Pelvic exenteration: Removes the rectum, bladder, prostate in men or uterus in women. This surgery will require a colostomy to remove stool and at times a urostomy to remove urine.
  • Diverting colostomy:  A rectal blockage can be relieved by placing a diverting colostomy (ostomy placed above the tumor in the GI tract).
  • Surgery for metastatic disease: At times, rectal cancer may spread to other parts of the body, such as the lungs or liver, and it may need to be removed. These procedures depend on several factors which your healthcare provider will discuss with you.

Note: Your surgeon may consider minimally invasive surgery with laparoscopy or robotic surgery, as well as nerve-preserving surgery which aims to preserve urinary and sexual function. Ask your provider which type of surgery is best for you. 

What are the risks associated with rectal cancer surgery?

As with any surgical procedure, there are risks and side effects linked with rectal cancer surgery. These risks and side effects may be:

  • Reaction to anesthesia.
  • Bleeding.
  • Blood clots.
  • Infection.
  • Anastomotic leak (leakage from the joined colon or anastomosis site).
  • Separation of the incision.
  • Adhesions/scar tissue.
  • Bowel obstruction.
  • Need for colostomy or ileostomy which can affect body image.
  • Potential erectile dysfunction, orgasm abnormalities, and impaired fertility in men.
  • Potential painful intercourse and loss of ability to carry a child in women.

What is recovery like?

Recovery from rectal cancer surgery depends on the extent of the procedure performed. A hospital stay is often required.

You will be instructed on how to care for your surgical incisions and/or ostomy and will be given any other instructions prior to leaving the hospital.

Your medical team will discuss with you the medications you will be taking, such as those for pain, blood clot, infection, constipation prevention and/or other conditions.

Your healthcare provider will discuss your particular activity restrictions depending on the surgery you have had and will give you specific parameters of when to call your healthcare team.

What will I need at home?

  • Thermometer to check for fever which can be a sign of infection.
  • Loose clothes and underwear.
  • Incision and/or ostomy care items, oftentimes supplied by the hospital/physician office.

How can I care for myself?

Depending on the extent of your surgery, you may need a family member or friend to help you with your daily tasks until you are feeling better and your medical team gives you the go ahead to resume normal activity.

Be sure to take your medications as directed to prevent pain, infection or other conditions and call your medical team with any concerning symptoms.

If constipation is present, speak with your healthcare team about recommendations they have to offer relief.

Deep breathing and relaxation are important to help with pain, keep lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to perform deep breathing and relaxation exercises several times a day in the first week, or whenever you notice you are particularly tense.

  • A simple exercise to do on your own: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This hand-out provides general information only. Please be sure to discuss the specifics of your surgical plan and recovery with your surgeon.

References

National Cancer Institute. Rectal Cancer Treatment (PDQ®)–Patient Version. 2018. Found at: http://www.cancer.gov/types/colorectal/patient/rectal-treatment-pdq 

American Cancer Society. What is Colorectal Cancer? 2018. Found at: http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-what-is-colorectal-cancer 

American Cancer Society. Surgery for Rectal Cancer. 2018. Found at: http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-treating-rectal-surgery 

MSKCC. Surgery for Rectal Cancer. Found at: https://www.mskcc.org/cancer-care/types/rectal/treatment/surgery 

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